Patients without insurance have significantly shorter hospital stays than patients with insurance, raising worrisome concerns that hospitals may have increased incentive to release these patients earlier to reduce their own costs of uncompensated care. Analyzing nationally representative data on a weighted sample of more than 90 million hospitalizations between 2003 and 2007 of patients aged 18 to 64 years, researchers found across all hospital types (for-profit, nonprofit and government), the average length of stay for preventable hospitalizations (thought to be avoidable with the use of appropriate preventive care and disease management) was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days) or Medicaid (3.19 days). For patients hospitalized for other diagnoses, the average length of stay was also shorter for uninsured patients (2.74 days) than for those with private insurance (2.86) or Medicaid (3.13). In terms of in-hospital mortality for patients with hospitalizations for non-preventable conditions, researchers found patients without insurance were at a higher likelihood of death in both for-profit and nonprofit hospitals. They found no significant difference in mortality among patients hospitalized for preventable conditions, though the limited number of deaths limited the analysis. The authors call on clinicians to advocate for all patients to be treated equally no matter what type of health insurance or payment type is being provided for services.

Impact of Insurance and Hospital Ownership on Hospital Length of Stay Among Patients With Ambulatory Care-Sensitive Conditions

By Arch G. Mainous, III, PhD., et al

Medical University of South Carolina, Charleston

Children More Likely to Have Unmet Health Care Needs if Parents Lack a Medical Home

Children whose parents lack a usual source of health care a place they routinely go to for health care, such as a physician's office or clinic typically receive fewer recommended health care services and experience more unmet needs, regardless of the child's usual source of care and insurance status. Analyzing nationally representative data on 56,302 children participating in the Medical Expenditure Panel Survey, researchers found among the 12.4 percent of children who had a usual source of care but whose parents did not, there was a higher likelihood of an insurance coverage gap (aRR 1.33), having no doctor visits in the past 12 months (aRR 1.11), no yearly dental visits (aRR 1.12) and unmet medical or prescription needs (aRR 1.70), when compared with children with a usual source of care whose parents had a usual source of care. These findings highlight the need to consider the role parental access to health care plays in ensuring access to health care services for children. The authors assert there is a clear need to advocate for policy changes that improve access to a usual source of care for all family members. They conclude that keeping the entire family in mind when crafting any new reforms will be essential to achieving a sustainable health care system and the best possible health outcomes for children.

Examining the effects of the closure of a large safety-net hospital in Los Angeles, Calif., on local primary care physicians, researchers found clinicians experienced profound clinical, professional and personal upheaval because of the overburdened system that resulted from the disruption in the network of care. Interviews with 42 local primary care physicians revealed numerous challenges that resulted from the loss of services, including reduced access to specialty care, overcrowding of other area hospitals and emergency departments, delayed and poorer quality of care for patients, reduced communication and disrupted patient connections, and a loss of colleagues and opportunities to teach residents and medical students. The authors conclude that primary care physicians should be informed and consulted when a major disruption to the health care delivery system is planned. They call for greater recognition of and support for the role primary care physicians play in coordinating care, promoting continuity of care and counseling patients and others about system changes during such transitions.

Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians' Perceptions of Their Role in Patient Care

By Kara Odom Walker, MD, MPH, MSHS, et al

University of California, San Francisco

Editorial: Why the United States Continues to Fall Further Behind
In an accompanying editorial, Robert L. Phillips, Jr., MD, MSPH, director of The Robert Graham Center for Policy Studies in Family Practice and Primary Care, uses the articles by Mainous, DeVoe and Odom Walker to illustrate three major problems facing the United States' health care system 1) lack of robust and comprehensive primary care, 2) insufficient access to timely care for a large portion of the population, and 3) incapacity take a population view of health. He concludes the Patient Protection and Affordable Care Act has important provisions that may help address some of these problems by helping to build more robust and comprehensive models of primary care.

Where the U.S. Falls Down and How We Might Stand Up

By Robert L. Phillips, Jr., MD, MSPH

The Robert Graham Center, Washington, D.C.

Essay: Physicians Should Leverage Their Authority Within the Community to Advocate for Healthier Lifestyles
In a compelling essay, a family physician posits a pathway by which greater physician advocacy for environmental change can help to assuage the epidemic of childhood obesity. Pointing out that this public health crisis resides in the community and demands environmental interventions, she calls for physicians to go beyond addressing lifestyle issues in the office and to engage with the community to affect environmental and policy change. U.S. physicians, she asserts, can synergize with efforts such as the White House Task Force on Childhood Obesity and the Surgeon General's emphasis on changing the national conversation "from a negative one about obesity and illness" to a positive one about health and fitness.

Researchers in the Netherlands conduct an analysis of 250 random disciplinary law verdicts concerning Dutch family physicians between 2008 and 2010 and find a wide range of complaints, 74 of which included a serious outcome, most commonly related to a wrong diagnosis (45 percent) or insufficient care (23 percent). They conclude the Dutch disciplinary system, which differs fundamentally from a legal malpractice system in that it offers no potential financial benefit for patients involved, can be useful for learning about medical errors with the goal of improving patient safety. Because this analysis uncovered serious patient safety incidents not detected by other methods, including large-scale medical record review or incident reporting, they call for researchers to include disciplinary law verdicts in patient safety studies.

An accompanying editorial uses the Dutch study findings and the analogy of a lightning strike to remind readers that medical errors do happen, aren't random and can be prevented. The author calls on the health care community to view error reports as opportunities for improvement from which people can gain a better understanding of why, when and how medical errors occur so they can be avoided and managed.

Complaints Against Family Physicians Submitted to Disciplinary Tribunals in the Netherlands: Lessons for Patient Safety

As the U.S. health care system moves rapidly to encourage the transformation of traditional primary care practices into patient-centered medical homes, researchers find reasons for avoiding unrealistic expectations about the rate of improvement in health or patient experience that will result. Describing trends in quality and patient satisfaction in 21 Minnesota primary care clinics as they worked toward level III recognition as medical homes by the National Committee for Quality Assurance, researchers find a 1 percent to 3 percent increase per year in patient satisfaction and a 1 percent to 4 percent increase per year in performance on quality measures. When compared with the average for other medical groups in the region, the rates of increase were greater for satisfaction, but similar for quality measures. They conclude that national policy makers' expectations for large and rapid change are probably unrealistic.

A multimodal approach to improving guideline implementation for cholesterol screening and management in primary care using a PDA-based physician decision support tool and patient activation kiosks in waiting rooms showed no benefit in an intent-to-treat analysis. Post hoc analysis appeared more promising, showing benefit regarding screening and improved LDL and non-HDL cholesterol goal attainment. Specifically, in post hoc analysis, researchers found practices reporting above-median use of the patient activation kiosk were more likely to have patients screened (OR = 2.54) than those with infrequent or no use. Physicians with above-median use of the PDA decision support tool were more likely to have their patients at LDL cholesterol goals (OR = 1.27) and non-HDL goals (OR=1.23) than physicians with below-median or no PDA use. The researchers call for more research on how to incorporate and increase adoption of user-friendly, patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors.

Researchers developed and tested a new patient questionnaire designed to measure the depth of the patient-doctor relationship in primary care, asserting the instrument may provide a more meaningful way to examine the value of patient-doctor continuity to care processes and patient outcomes. The final 8-item instrument showed high internal reliability and had good test-retest reliability.

Patient-Doctor Depth-of-Relationship Scale: Development and Validation

By Matthew J. Ridd, et al

University of Bristol, United Kingdom

Balint Group Helps a Physician Through the Emotional Process of Leaving Practice

An essay by Shorer and colleagues depicts how Balint group involvement leads a physician to recognize her conflicted feelings about leaving her practice and to proactively plan her departure. The authors conclude these closed peer discussion groups offer physicians a secure, nonjudgmental place for emotional reflection.

Family Physicians leaving Their Clinic The Balint Group as an Opportunity to Say Good-byeBy Yuval Shorer, MD, et al

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